Cancer of the Hypopharynx and Cervical Esophagus
Parul Sinha
Bruce H. Haughey
Cancer of the hypopharynx and cervical esophagus often present significant challenges in management, owing to the critical role these anatomical sites play in the normal function of the upper aerodigestive tract (UADT). The structural proximity, close physiologic coordination, and similarity in oncologic aspects allow concurrent discussion of cancer arising from the two sites. Treatment of cancer of the hypopharynx and cervical esophagus includes the use of surgery, radiotherapy, and chemotherapy in different combinations depending upon the stage of the cancer. With a growing emphasis on organ preservation, the selection of therapeutic option, surgical or nonsurgical, which maximally controls disease and preserves function, remains critical. This chapter focuses on the approaches to the management of cancers of the hypopharynx and cervical esophagus with relevant anatomic, pathologic, and etiologic details.
SURGICAL ANATOMY
The hypopharynx extends from its junction with the oropharynx at the level of the tip of the epiglottis to its junction with the cervical esophagus inferiorly (Fig. 16.1). The bony landmarks are the hyoid superiorly, the lower border of the cricoid cartilage inferiorly, and C3 to C6 vertebrae posteriorly. The hypopharynx is comprised of three anatomical subsites—the pyriform sinus (PFS), the postcricoid area, and the posterior pharyngeal wall. These three subsites are continuous with one another and cancers often involve more than one subsite.
The PFS is a conical structure located on each side of the hypopharynx that extends from the pharyngoepiglottic fold down to its inferior-most extent, the apex, which opens medially into the cervical esophagus. The superior part of the PFS is bounded by the thyrohyoid membrane and thyroid cartilage laterally and the aryepiglottic fold (AEF) and arytenoid cartilage medially. The apex of the PFS is bounded by the thyroid cartilage laterally and by the cricoid cartilage medially. The medial wall of the PFS is separated from the endolarynx by the AEFs.
The postcricoid area extends from the level of the arytenoid cartilages to the inferior border of the cricoid cartilage at the pharyngoesophageal junction. It lies in close proximity to the posterior cricoarytenoid muscles and the medial wall and apices of the PFSs.
The posterior wall of the hypopharynx extends from the level of the tip of the epiglottis (or the floor of the vallecula) to the level of the inferior border of the cricoid cartilage. The superior and inferior boundaries of the posterior wall of the hypopharynx merge with the walls of the oropharynx and the esophagus, respectively, whereas the lateral boundaries are continuous with the PFS. The mucosal lining of the wall of the hypopharynx is separated from the prevertebral space by a fibrous layer formed by the pharyngeal aponeurosis; a muscular layer formed by the middle and inferior constrictors; the buccopharyngeal fascia; the retropharyngeal space; and the prevertebral fascia. The distal-most fibers of the inferior constrictor muscles form the cricopharyngeus muscle, which constitutes the primary muscle of the upper esophageal sphincter and marks the junction between the postcricoid area and the cervical esophagus.
The cervical esophagus lies posterior to the trachea and thyroid gland, extending from the inferior border of the cricoid cartilage (opposite C6 vertebra) to the level of the thoracic inlet (opposite T1 vertebra). It deviates to the left in the inferior aspect of the neck and is medial to the common carotid artery and recurrent laryngeal nerve on either side and the thoracic duct on the left. The esophageal wall from inside out is made up of a mucosal, submucosal, muscular, and an external fibrous layer. The muscular layer consists of internal circular fibers, which are continuous with the cricopharyngeus muscle, and external longitudinal fibers that are covered with a fibrous layer in continuity with the wall of the hypopharynx.
Nerve supply: The pharyngeal constrictor muscles receive motor innervation through the pharyngeal plexus with additional innervation of the inferior constrictors from branches of the external laryngeal and the recurrent laryngeal nerves. The recurrent laryngeal nerve provides motor innervation to the cricopharyngeus and the posterior cricoarytenoid muscles, whereas the sensory innervation of the hypopharynx is derived primarily from the internal branch of the superior laryngeal nerve. This branch synapses with a branch of the vagus, Arnold’s nerve, which provides sensation to the external auditory canal and which accounts for the symptom of referred otalgia from cancer of the hypopharynx. Additional sensory innervation is also provided by branches of the recurrent laryngeal nerve. Innervation to the cervical esophagus is derived from the recurrent laryngeal nerve and sympathetic chain.
Vascular supply: The superior laryngeal branch of the superior thyroid artery is the primary blood supply to the superior aspect of the hypopharynx; the inferior part is supplied by the inferior laryngeal branch of the inferior thyroid artery. The vascular supply of the cervical esophagus is derived primarily from the inferior thyroid artery. Venous drainage from the hypopharynx occurs through the submucosal pharyngeal venous plexus, which drains into the internal jugular vein, whereas the cervical esophagus drains into the inferior thyroid vein.
Lymphatic drainage: The hypopharynx is rich in lymphatics, which pierce the thyrohyoid membrane to drain into the deep jugular chain (level II, III, and IV) nodes. Lymphatics from the inferior aspect of the PFS and the postcricoid area pierce the cricothyroid
membrane and drain into the paratracheal chain (level VI) nodes. From the posterior pharyngeal wall, drainage occurs into the retropharyngeal nodes (RPLNs) including the nodes of Rouviere superiorly. Lymphatics from the cervical esophagus usually drain first into the paratracheal and paraesophageal nodes, and second, into the cervical and superior mediastinal nodes.
membrane and drain into the paratracheal chain (level VI) nodes. From the posterior pharyngeal wall, drainage occurs into the retropharyngeal nodes (RPLNs) including the nodes of Rouviere superiorly. Lymphatics from the cervical esophagus usually drain first into the paratracheal and paraesophageal nodes, and second, into the cervical and superior mediastinal nodes.
 Figure 16.1. Anatomical subdivisions of the pharynx (posterior view). |
PATTERNS OF SPREAD
Cancers from the medial wall of the PFS spread medially to the endolarynx by invading the AEF or the paraglottic space causing fixation of the hemilarynx. Posterior extension into the postcricoid area can lead to infiltration into the posterior cricoarytenoid muscle with fixation of the ipsilateral vocal cord. Infrequently, fixation of the hemilarynx can also result from the direct invasion of the cricoarytenoid joint or the recurrent laryngeal nerve. Anterior and lateral spread leads to involvement of the lateral wall of the PFS and/or the wall of the hypopharynx. From the lateral wall of the PFS, cancer can extend into the cervical soft tissues to involve the strap muscles, thyroid gland, and other extralaryngeal structures through direct invasion of the thyroid cartilage or by spread around the posterior border of the thyroid cartilage at the insertion of the inferior constrictor muscles. Posterior extension involves the posterior wall of the hypopharynx, whereas the lateral wall of the oropharynx, pharyngoepiglottic fold, and the base of the tongue can be involved by superior extension.
Cancers reaching the apex of the PFS can involve directly the postcricoid area and the cricoid cartilage. Cancers of the postcricoid area can extend directly to the cricoid cartilage and the trachea and, submucosally, toward the cervical esophagus. Submucosal spread of cancer superiorly to the oropharynx and inferiorly to the esophagus can also occur from the posterior wall of the hypopharynx. Cancers from this site can involve the pharyngeal constrictors and the buccopharyngeal fascia. The fascia is a weak barrier, and further posterior spread can involve the prevertebral fascia and the prevertebral musculature, ultimately reaching the periosteum of the vertebral column.
Cancers of the cervical esophagus can spread anteriorly to the trachea, laterally to the tracheoesophageal groove and recurrent laryngeal nerve(s), and posteriorly to the prevertebral space.
EPIDEMIOLOGY
Cancer of the hypopharynx is rare and accounts for 3% to 5% of the malignancies in the UADT.1 The American Cancer Society estimates 3,400 cases in 2014, ˜2,725 in men and 675 in women. The worldwide age-standardized incidence estimated by GLOBOCAN 2012 report from the International Agency for Research on Cancer (IARC) is 1.9 per 100,000 and a total number of 142,387 new cases.2 The precise incidence for either the hypopharynx or the individual hypopharyngeal subsites is, however, difficult to estimate due to the combined reporting on all cancers of the pharynx by the IARC. In addition, a marked gender and geographical variation is known to exist, with a higher incidence in males and in certain regions of Central and Eastern Europe, France, and Southeast Asia.
Cancer of the PFS and posterior hypopharyngeal wall occurs predominantly in males, aged 55 to 70 years, and is strongly associated with excessive alcohol consumption and smoking. Carcinoma of the postcricoid area is more common in females, aged 30 to 50, with underlying nutritional factors such as Plummer-Vinson syndrome as a possible etiology. It is mainly reported from Sweden and other Scandinavian nations; however, improved nutrition has been shown to decrease the incidence of Plummer-Vinson syndrome and, therefore, the incidence of postcricoid carcinoma from these regions.3,4 Chronic gastroesophageal reflux and human papillomaviruses are postulated to have an etiologic association to cancer of the hypopharynx in nonsmokers and nondrinkers.5 Genetic predisposition and occupational exposure to carcinogens such as solvents, polycyclic aromatic hydrocarbons, sulfuric acid, asbestos, welding fumes, wood dust, nickel, and leather have also been implicated as etiologic factors.3
Cancers involving the cervical esophagus make up 2% to 10% of all cancers of the esophagus and are derived from the caudal extension of cancers originating in the hypopharynx.6,7 Cervical esophageal cancer is predominantly seen in males and has a high incidence in certain regions of Iran, Central Asia, Mongolia, and Northern China. The risk factors for the development of cancer of the cervical esophagus are similar to those for the hypopharynx. Prolonged irritation from thermal injury or corrosives such as lye is also associated with increased risk.
HISTOPATHOLOGY
Approximately 95% of the cancers of the hypopharynx and cervical esophagus are squamous cell carcinomas (SCC). Invasive SCC may be preceded by premalignant lesions. The PFS is the most common site of involvement, accounting for 65% to 85% of the hypopharyngeal SCC, followed by the posterior wall of the hypopharynx (10% to 20%) and the postcricoid area (5% to 15%). Submucosal spread and skip lesions are an important characteristic of cancers arising from these sites; spread of 5 to 30 mm beyond macroscopically visible cancer has been observed.8 Whereas cancers of the PFS and posterior pharyngeal wall are more frequently exophytic, postcricoid cancers are more commonly ulcerative. Basaloid carcinoma, undifferentiated carcinoma, and spindle cell carcinoma are rare SCC variants characterized by more aggressive behaviors.9 Spindle cell carcinoma occurs mostly in patients with a history of prior radiation that typically presents as a polypoid mass projecting into the pharyngeal lumen.10 The hypopharynx and cervical esophagus can also give rise to malignant nonsquamous tumors such as, (1) minor salivary gland adenocarcinoma and adenoid cystic carcinoma; (2) sarcomatous lesions such as fibrosarcoma, leiomyosarcoma, liposarcoma, and synovial cell sarcoma; (3) reticuloendothelial tumors such as lymphoma and plasmacytoma; and (4) melanoma.
TUMOR BIOLOGY
Site-specific chromosomal aberrations are not so well defined in carcinomas of the head and neck; however, 11q13 amplification and loss of p53 heterozygosity have been reported in 78% and 70% of hypopharyngeal SCCs, respectively. The presence of 11q13 amplification has been associated with nodal metastases, greater local aggressiveness, and higher recurrence rates.11 A loss of chromosome 18 has also been observed in 57% of cancers of the hypopharynx.12
CLINICAL PRESENTATION AND EVALUATION
Presenting Symptoms and History
The common presenting symptoms, which suggest cancers originating from the hypopharynx and cervical esophagus, are progressive dysphagia, odynophagia, sore throat, referred otalgia, weight loss, and/or a mass in the neck. These cancers usually present at an advanced stage because the nonspecific symptoms of minor irritative sensation or sore throat from early-stage cancer may be too easily dismissed. Aspiration, hemoptysis, and weight loss occur with advanced cancer. Persistent pain in the throat with referred otalgia may be indicative of perineural invasion. Hoarseness and breathing difficulty are indicative of laryngeal involvement. Metastases to the cervical lymph nodes are known to occur in 50% to 80% of the patients at presentation, and not infrequently, patients may present with only a metastatic mass in the neck in the absence of any of the aforementioned symptoms related to the primary cancer.1,13 A thorough history should be elicited about prior risk factors including alcohol and smoking habits, laryngopharyngeal or gastroesophageal reflux, nutritional status, Plummer-Vinson syndrome, and occupational exposures; past treatments such as radiation and/or chemotherapy; and general medical condition including coexisting pulmonary or cardiovascular comorbidities.
Physical Examination
A complete examination of the head and neck including an indirect or fiberoptic laryngoscopy to evaluate the pharynx and larynx is the first step in the diagnostic evaluation. The site and extent of the cancer, vocal cord mobility, airway patency, and mobility and appearance of the arytenoids are assessed. Maneuvers such as phonation and/or Valsalva with a pinched nose offer better visualization of the PFSs with fiberoptic endoscopy. In the absence of a frank mass or surface ulceration, findings of pooling of saliva in the PFS, an edematous arytenoid, or submucosal swelling in the posterior pharyngeal wall should raise suspicion of a malignant lesion. Cancers confined to the postcricoid area often evade detection in office laryngoscopy but can be suspected in the presence of edematous arytenoids and/or fixed hemilarynx. Anterior traction on the larynx by grasping the overlying skin and pulling forward may improve the view.
The examination of the neck should include careful palpation on both sides and assessment for number, level, size, and mobility of any enlarged lymph nodes. Tenderness over the lateral expansion of the laryngeal framework or upper trachea
may suggest cancer invasion. A side-to-side movement of the laryngeal framework is recommended to assess the laryngeal crepitus at the level of thyroid cartilage. Fixation of cancer to the prevertebral fascia or anterior displacement of the larynx by advanced postcricoid and posterior wall tumors can result in loss or restriction of laryngeal crepitus.
may suggest cancer invasion. A side-to-side movement of the laryngeal framework is recommended to assess the laryngeal crepitus at the level of thyroid cartilage. Fixation of cancer to the prevertebral fascia or anterior displacement of the larynx by advanced postcricoid and posterior wall tumors can result in loss or restriction of laryngeal crepitus.
Imaging
Radiologic studies such as contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) are performed to complete the diagnostic evaluation. Compared to CT, MRI is more susceptible to motion artifacts from swallowing, coughing, or any other movement and is usually the second line of investigation; it may however be preferred to assess cancers that recur after resection or chemoradiation for better tissue delineation.3 Radiology complements physical examination with information about the inferior extent of cancer, submucosal spread, invasion of the thyroid cartilage, and extralaryngeal involvement. Involvement of the prevertebral fascia or space should be ruled out for the primary cancers arising from or extending to the posterior wall of the pharynx. Imaging can also reveal the presence of a synchronous primary cancer, which is known to have a high incidence in the hypopharynx and cervical esophagus due to field cancerization effects from chemical carcinogens. Barium swallow is helpful in ruling out an esophageal cancer. It also facilitates diagnosis of esophageal motility disorders in patients with progressive dysphagia with no risk factors for SCC and a normal physical examination. Endoscopic ultrasonography is considered to be a more accurate imaging technique in determining the T stage of cancers of the cervical esophagus.
Ultrasonography and CT are of help in an accurate search for lymph node metastases; the latter is superior in demonstrating RPLN metastases. High rates of distant metastases of 10% to 30%1,14,15 are associated with cancers of the hypopharynx and cervical esophagus. Hence, screening with whole-body positron emission tomography (PET) or chest and abdominal CT scans is recommended, particularly in patients with prolonged symptoms and bulky lymph node metastases.
Endoscopy Under Anesthesia and Biopsy
Examination under anesthesia (EUA) of the pharynx, larynx, trachea, and esophagus under anesthesia with rigid endoscopes is fundamental to accurately evaluate the cancer site and stage and detect synchronous primary cancer of the UADT. A rigid esophagoscopy is required to assess spread of the cancer to the cervical esophagus and to rule out a synchronous esophageal primary cancer. EUA allows tissue biopsy for diagnostic confirmation, although a histologic diagnosis can be achieved with fine-needle aspiration in patients with palpable neck nodes. In patients with advanced cancers and widely scattered foci of dysplastic-appearing mucosa in the UADT, mapping biopsies are a useful aid to predict resectability. Mapping biopsies are also important for chemoradiation-recurrent cancers; many of these cancers do not exhibit typical clinical or radiologic findings, and malignant tissues may lurk beneath intact mucosa far distant from the epicenter of the primary cancer. Palpation of the cancer and movement of the cancer over the prevertebral fascia help to ascertain fixation for cancer of the posterior wall of the hypopharynx. Bronchoscopy is recommended for patients with cancer of the cervical esophagus in order to detect anterior extension of the cancer or a synchronous primary cancer. Based on information from clinical, radiologic, and endoscopic evaluations, a final clinical tumor stage (cT) is determined (Table 16.1) according to the American Joint Commission Cancer (AJCC) staging system. EUA for cancer of the hypopharynx also gives an opportunity to determine the access and feasibility for resection via a transoral approach. In cases unsuitable for transoral resection, assessment is directed toward decision-making for conservation versus radical surgical approaches and/or nonsurgical management. Assessment of the extent of the anticipated pharyngeal defect from surgical resection, as well as the most appropriate type of reconstruction, should be made during EUA. For patients likely to undergo a flap reconstruction, a donor site and potential alternatives should be planned.
Additional Investigations
Routine hematologic and blood chemistry investigations are performed as part of pretreatment evaluation. Assessment of iron deficiency is particularly relevant in females with features of Plummer-Vinson syndrome. Protein deficiency and overall nutritional status should also be evaluated, and corrective measures initiated prior to initiation of treatment. The cachectic patient may benefit from pretreatment insertion of a percutaneous endoscopic gastrostomy (PEG) tube. A majority of patients are heavy smokers; hence, pulmonary reserve is checked with careful history and pulmonary function tests, and referrals to tobacco cessation programs are made. Patients with poor pulmonary reserve may not be candidates for transoral or open conservation surgery due to the high risk of developing pulmonary complications from postoperative aspiration. Assessment of dentition is done during office examination, and referral is made to a specialist if restorative procedures or dental extractions are required, particularly for patients who are planned to receive radiation as part of the treatment.
TREATMENT
Among all cancers of the UADT, SCC of the hypopharynx and cervical esophagus are known to have an unfavorable prognosis. Treatment is aimed at achieving locoregional control with improved survival and a good functional outcome. Resectability of the primary cancer and nodal metastasis, medical comorbidities, pulmonary function status, patient preference, and distant metastasis at presentation are the important considerations in making treatment decisions. Surgery followed by adjuvant treatment for adverse features is the most commonly used approach for treatment of cancer of the hypopharynx. 5 Single modality therapy with surgery or radiation alone may be an effective therapeutic approach for early T1 or T2 disease, but most of these cancers are diagnosed at a more advanced stage. For advanced cancer, the most common conventional treatment approach has been partial or total pharyngectomy with a total laryngectomy. With a goal to cure and to preserve the larynx, nonsurgical treatment approach with various chemoradiation protocols started to gain favor in the late 1990s.1,16 The risk of long-term toxicity, principally dysphagia and aspiration, from chemoradiation and poor outcomes after salvage surgery for postchemoradiation-recurrent tumors16,17,18 rekindled interest in organ-preserving, conservative surgical approaches including transoral laser microsurgery (TLM).
For SCC of the cervical esophagus, radical surgery with laryngopharyngoesophagectomy and adjuvant radiotherapy was regarded as the gold standard of treatment. Nonsurgical approaches have been employed as alternatives to radical
resection; newer, minimally invasive thoracoscopic surgery is also evolving for early cancers of this site.
resection; newer, minimally invasive thoracoscopic surgery is also evolving for early cancers of this site.
Table 16.1 American Joint Committee on Cancer T and N Staging of Hypopharynx and Cervical Esophagus Cancer (2010) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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SURGICAL TREATMENT
The goal of surgery is to achieve a resection with clear margins with or without laryngeal preservation, and extent of surgery is dictated by the site of the cancer, its stage, and functional status at presentation as well as the patient’s pulmonary reserve. Extension of cancer to the vertebral column and mediastinal structures and encasement of the carotid artery(s) are often features associated with unresectable cancer. When feasible, conservation surgery is performed with the objective to cure, minimize operative morbidity, and maximize function and quality of life (QOL). Laryngeal preservation with a transoral approach facilitates faster recovery of swallowing compared to conventional, open conservation approaches, due to better preservation of suprahyoid musculature, constrictor muscle, and the pharyngeal neural plexus.
Transoral Approaches
Transoral Laser Microsurgery
TLM as an approach for the management of hypopharyngeal SCC was first reported by Steiner in 2001.19 When feasible, this approach reduces the need for permanent tracheotomies or feeding tube dependency by avoiding resection of tissues that are critical for airway, speech, and swallowing functions. The application of TLM to resect select advanced SCC of the hypopharynx has broadened as experience and technology advance.
Contraindications: Inadequate access is the most important contraindication for TLM resection of cancer of the hypopharynx. Extensive invasion of the larynx and base of the tongue and bilateral arytenoid extension or fixation preclude function-preserving conservation surgery, and thus, patients with these features will not benefit from transoral
resection. Circumferential or near-circumferential spread to the cervical esophagus, gross invasion of the cricoid cartilage, significant extralaryngeal spread, and encroachment on major vessels in the neck are other contraindications for TLM in cancer of the hypopharynx. Patients with cancer of the posterior pharyngeal wall with invasion into the prevertebral and parapharyngeal spaces are also not suitable for TLM.
resection. Circumferential or near-circumferential spread to the cervical esophagus, gross invasion of the cricoid cartilage, significant extralaryngeal spread, and encroachment on major vessels in the neck are other contraindications for TLM in cancer of the hypopharynx. Patients with cancer of the posterior pharyngeal wall with invasion into the prevertebral and parapharyngeal spaces are also not suitable for TLM.
Technique: Resection in TLM is performed using the principles first popularized by Steiner.20 Access is achieved with a combination of distending or fixed bore laryngoscopes (e.g., Steiner, Kleinsasser, Lindholm) or bivalved scopes. A key maneuver to enhance exposure of the tumor and surrounding landmarks, especially in patients with redundant, collapsing mucosa, is to maximally suspend and distend the long Steiner endoscope, thus creating luminal working space. For exophytic cancers, debulking at the onset also creates improved exposure of the surgical field. The CO2 laser beam is usually delivered to the operative site via a micromanipulator attached to the operating microscope. TLM is initiated with a transtumoral incision, which transects the cancer for depth estimation, and is completed by multibloc resection until negative margins are obtained (Fig. 16.2). Mucosal margins of at least 5mm for superficial and 10mm for infiltrating cancers are recommended; however, confirmation of margin-negative resection by frozen sections from the perimeter of the resection defect is fundamental to the TLM technique. The principles of TLM resection of SCC of the hypopharynx are outlined in Table 16.2, and hypopharyngeal subsite-specific resection techniques are discussed below.
Pyriform sinus: Resection commences proximally and advances distally in a craniocaudal direction,20 widening the exposure as incisions are made around the anterior extent from the lateral toward the medial side (Fig. 16.3). Another approach is first to divide and resect the AEF and then proceed on to removal of the anterior and lateral components. Extension into the pre-epiglottic space is also addressed early in a TLM approach, thereby facilitating exposure. For cancers involving the medial PFS that approach, but do not frankly invade, the AEF and the arytenoid cartilage, complete oncologic clearance can be achieved by carefully peeling the mucosa from the surface of the arytenoid without sacrificing the cartilage itself. This technique minimizes the risk of aspiration versus a more extensive arytenoidectomy to facilitate postoperative swallowing. In patients for whom the arytenoid needs to be resected, preservation of at least one functional arytenoid is required to prevent aspiration. For cancers of the lateral PFS that approach the thyrohyoid membrane, the membrane may be excised as a margin and the tumor is followed out to the strap muscles, if required. Thyroid perichondrium may also be stripped off to ensure clear margins, but delayed healing may result. For cancers that infiltrate the thyroid cartilage, the involved areas of the cartilage are resected along with accessible extracartilaginous extensions. For extensions of the cancer that are not completely accessible, the transoral approach can be combined with a lateral pharyngotomy parallel to and posterior to the thyroid lamina, using the access provided by the neck dissection. This approach is also used in situations where there is inadequate access to resect extensions of the cancer of the PFS. The pharyngotomy or laryngotomy is repaired by advancement of the constrictor muscles and adjacent strap muscle and/or an additional patch of cadaveric acellular dermis.
 Figure 16.2. Sequential incisions and multibloc design for TLM resection of the medial wall of the right pyriform sinus/aryepiglottic fold (AEF) cancer ([1] transverse transtumoral cut, [2] longitudinal, splitting posterior AEF cut, [3 and 4] completion medial [3] and lateral [4] AEF/arytenoidectomy cuts at perimeter, [5] anterior AEF, lateral epiglottic and PFS wall cut). |
Table 16.2 Requisites and Fundamental Principles of Hypopharynx SCC Management with TLM Approach | ||||||
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Postcricoid area: TLM can be used for cancers that are superficial and confined to the postcricoid area. For cancers with minimal inferior extension into the esophageal inlet, a
long expanding or bivalved laryngoscope is used to gain access. Excision is performed down the upper esophagus in separate blocs by making longitudinal, then curvilinear incisions around the inlet and assessing the specimen for complete clearance of the cancer with a margin of normal esophageal mucosa. No more than 180 degrees of the circumference should be demucosalized. Because the operative field is very close to the posterior cricoarytenoid muscle, resection should be extremely cautious because there is a high risk of postoperative airway compromise due to injury to the sole abductor muscle of the vocal cord.
long expanding or bivalved laryngoscope is used to gain access. Excision is performed down the upper esophagus in separate blocs by making longitudinal, then curvilinear incisions around the inlet and assessing the specimen for complete clearance of the cancer with a margin of normal esophageal mucosa. No more than 180 degrees of the circumference should be demucosalized. Because the operative field is very close to the posterior cricoarytenoid muscle, resection should be extremely cautious because there is a high risk of postoperative airway compromise due to injury to the sole abductor muscle of the vocal cord.
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